SHINPU-REN FAMILY KARATE * PRESCOTT VALLEY * CONSENT FORM
NAME _______________________________________ AGE _______ DATE _________ ADDRESS _____________________________________________________________ CITY ________________________________ ST ______________ ZIP _____________ PHONE: HM: ____________________________ WK: ___________________________ 1.The member acknowledges that this agreement, including the rules, regulations and conditions set forth by the instructor (SENSEI) are acknowledged. Thus made part hereof constitutes the entire agreement of the parties and that no other agreement exists between them. ShinPu-Ren Family Karate has made no express or implied warranties or representation other than those expressed in this agreement to induce the member to enter into this agreement. 2.Members will be asked to purchase protective gear for their own safety. Member acknowledges that KARATE is a contact sport and that even with protective gear the possibility of injury or death could occur. (INT.____) Members and instructors will not be held liable for injuries occurred during the course of instructions. Furthermore, Member acknowledges that ShinPu-Ren Family Karate is not responsible for loss or injury to any property belonging to any member, or any guest of any member, occurring while the member or guest is in, or about the training facility or premises of ShinPu-Ren Family Karate. The Member agrees to indemnify and hold harmless ShinPu-Ren Family Karate from any and all liabilities, damages and costs incurred, or arising out of the conduct or activity of the Member or any guest of the member. Member Signature__________________________________________ Date _________ Parent or Legal Guardian Signature__________________________________________ Who to notify in case of emergency___________________________________________ ______________________________________________________________________ HM:_____________________ WK:_____________________ CELL ________________
(YES) I release SPRFK to use my photos for school use and purposes
(NO) I do not release SPRFK to use my photos for school use and purposes